right care initiative team based care: a local example 12/10/12 phillip raimondi md bridget levich...
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RIGHT CARE INITIATIVETEAM BASED CARE: A LOCAL EXAMPLE
12/10/12
Phillip Raimondi MD
Bridget Levich MSN, CDE
University of California Davis Medical Center
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Three Care Management Projects:
Lessons Learned
Diabetes Care Management
Heart Failure Care Management
Depression Care Management
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Diabetes Care Management
2 year Pay for Performance Funded Project
utilized team* - reached out to patients identified via EMR reports to have suboptimal care and engage them in self-management activities
improved the coordination of care of patients with Type 2 diabetes and increase their follow-up, access to education and appropriate specialty care via care management.
*Team = LVN, Certified RN Case Manager, Pharmacist, Analyst, Statistician
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Diabetes Care Mgmt: Outcome Data 2011
* Values statistically significant
Patient experience (n=89) I appreciated being contacted by UCDHS to help me with my diabetes
care. 4.6 How would you rate your overall experience with this phone contact?
4.8 (79% excellent) Would you welcome being contacted by UC Davis Health System for
similar referrals in the future? 100% yes, including those who declined any offered services
CategoryPre Care
Mgmt(average)
Post Care Mgmt(90-180 days post,
average)Change
A1c (n=49)
7.9 7.5 -0.4*
BP (n=65)
141/80 131/75 -10*/-5*
LDL (n=32)
98 91 -7
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Heart Failure Care Management
1year Pay for Performance Funded Project (data being compiled)
Utilized a multi-disciplinary team: Certified Heart Failure RN, Pharmacist, PCP, Cardiologist – HF specialty, TOC team
Goals: increase primary care provider heart failure knowledge support heart failure patients reduce preventable ED visits, admissions and re-admissions to
hospital Primarily telephonic after one clinic visit in the PCN Education and medication needs addressed PCP kept in the loop Provide PCP Education series
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Heart Failure Outcomes
Data presently being compiled include: Appropriate medication regimen Medication adherance NYHA Functional Class Hospitalizations, re-admissions, ED visits
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Depression Care Management
2 year Pay for Performance Funded Project (presently finalizing data)
Goals: increase primary care depression
knowledge support patients with co-morbid
depression through telephonic contact
utilize multi-disciplinary team
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Depression Program Overview
8
Psychiatrist
Case Consults
LCSW
Telephonic Care
Management
PCP Educational Events
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PHQ-9 Scores: Average Reduction
2011 n=19
PRE: 19 Moderately
Severe POST: 12
Moderate depression
9
2012 n=45 and counting
PRE: 16Moderately
Severe POST: 9
Mild depression
Also: Improved PCP confidence and efficacy in treatment and appropriate drug selection
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Chronic Disease Management Care Coordination Program
Overarching goal to provide primary care providers support by:
Offering payor neutral, system wide, longitudinal patient support
Utilizing four resource groups to help manage patients
Reducing excessive PCP contacts/calls
Reducing inappropriate ED utilization
Reduce avoidable hospitalization/re-admits